private practice

Community Confidentiality: Supporting Collaboration with Consent

lovelanguagesbird.jpg

“I cannot confirm or deny.” How do you maintain confidentiality for your client? It may seem easy enough when there is a clearly written, signed release or when your client refuses a release, thus declining collaboration at this time. However, what does it look like in the following situations?

  • Your client is involved in an open Child Abuse and Neglect case.

  • An attorney calls you saying they represent your client and would like copies of your client record for a disability claim.

  • An insurance company calls to report the client listed you as a provider and they want to know your diagnosis to award the client a life insurance policy.

  • You outreach an organization about who they serve. They respond by wanting to obtain additional information from you on the client you want to refer.

  • A referral source wants to know if their client called to set up an intake and begin services with you.

  • A community resource shares that your client scheduled an appointment with them for next week.

  • A foster parent wants to know why the parent isn’t engaging in services to reunify with their child.

  • A CASA volunteer wants to know if the family is working on their fighting in your sessions because they believe it would be helpful.

  • The spouse of your client calls asking you how sessions are going.

  • Your client acknowledges that their friend is also your client.

  • Their probation officer includes you in a group text or email to schedule a meeting on behalf of the client with several parties you don’t know.

These are just a few of what could be dozens of examples of sticky situations when it comes to maintaining your client’s right to privacy. Let us look at possible responses to the above scenarios to determine what could be best. And as always, seek consultation, supervision, or legal advice if you have needs or concerns.

 

Signed Release

When a third party reaches out to you by email, text, or voicemail, it can be helpful to notify your client and obtain a release in the next scheduled session. Notifying your client of the outreach you received can support trust and transparency in the therapeutic relationship. It can also help facilitate a discussion on the importance of getting a client’s written permission to respond to an inquiry on their behalf, whether it’s an insurance company, secondary referral, family member, or community partner.

 

Legal Requirements

Perhaps your client is involved in an open Abuse and Neglect case, diversion, or probation. These entities have been assigned to your client as part of a larger treatment plan to address a legal concern. Whether your client is mandated to complete therapy or the third party referred directly to you, there is a different level of confidentiality implied due to the collaboration needed from you to provide progress reports and updates as appropriate around your client’s engagement in services. If you client is resistant to signing a release, helping them identify the specific pieces of information to share—and thus restricting some information in the effort of privacy—can be helpful to the client’s anxiety about personal information that is disclosed to others. When submitting a progress report to DHS or probation for example, providing your client with a copy can also demonstrate a sign of transparency and trust in encouraging them to review it and provide feedback on their level of comfort with the material shared.

 

Sense of Urgency

The desired scenario is one of those mentioned above, where we have the client complete a signed release of information highlighting exactly what is released and for what purpose. However, there are times that a sense of urgency may arise in getting permission quickly to collaborate with a community partner in a timely fashion. Depending on the frequency of client contact including regularly scheduled appointments, you may need to get email or verbal permission over the phone from your client as a temporary measure in obtaining consent prior to a written release. Standard practice is to have permission in writing so email can feel slightly more comfortable than verbal permission to us as providers. Either way, documenting your client’s permission with intention to get a full release in the immediate future can be helpful in allowing collaboration and sharing of information under a time restriction.

 

Curbing Curiosity

Collaboration is a helpful component of therapy, within reason, to support and validate client efforts. It may become apparent that there are other parties involved who may want updates on your client’s progress. This could include caseworkers, probation, child advocates, other mental health providers, foster parents and more. Where it can feel confusing is when third parties know you are actively working with the client and make assumptions that you can share information in the spirit of collaboration. For example, the foster parent is wanting to know how the parent, your client, is doing in services in order to encourage their child of the parent’s hard work. The inquiry may feel innocent enough, however the foster parent is not your client, and is therefore not privy to this information without your client’s consent. Something as innocent as attendance or participation in services can be reported back to other parties and could result in information being misconstrued or shared without permission.

 

Encompassing Electronics

In an effort to not have information shared unintentionally with third parties, being mindful of how your electronic correspondence is recorded can be helpful. Being aware of emails with additional recipients or group text messages requesting scheduling of a team meeting can feel nebulous regarding confidentiality. Documenting your effort to send correspondence only to approved parties identified on a signed release supports your client’s wishes as well as ethics compliance. Providing disclaimers in your electronic signature in email composed on your computer or phone can also support limiting liability if information is sent to the wrong recipient or forwarded to a third party outside of your control.

 

Limiting Liability

Documenting each of your efforts to maintain confidentiality as a standard of your practice can limit liability. Obtaining regular releases yearly from your client can keep their record up to date. Utilizing encrypted email and electronic health records for client progress notes can restrict situations where their information could be compromised. When it comes to confidentiality in direct interaction with third parties, identifying a statement of “I cannot confirm or deny they are my client” can feel unhelpful, restrictive but necessary in not admitting unapproved information to family, friends, referral sources, or legal representatives without permission. This feels most challenging by phone when even acknowledging your need to obtain a release is admission of your client’s connection to you. For many, having to share that a release has been revoked can feel even more challenging. You may say something like “permissions have been revoked and we suggest you contact the person of interest directly” can provide enough information for them to understand you won’t be interacting with them further and prevents direct identification of your client by name or circumstance.

Communication with community partners is an intricate dance that can feel challenging when caught off guard by emails, texts, or phone calls asking for updates on your client’s work. Demonstrating your ethical capacity in delaying disclosure of information until a release is obtained can indicate your professionalism in the community and willingness to collaborate under the appropriate circumstance. Be sure to follow up with the community partner once a release is signed to further demonstrate your willingness to collaborate together. Lastly, thinking about the possibly scenarios that put privacy at risk and obtaining signed releases upon introduction to the client can streamline this process by simply asking who else is involved in their treatment or care. Having a scripted response ahead of time for situations where a release is not yet completed can support you in making the best decision to support client confidentiality and community engagement with consent.

6 Reasons Highly Sensitive People (HSPs) Matter to Your Therapy Practice

Beauty Shot

If you aren’t familiar with the term Highly Sensitive Person (HSP) it refers to about 15-20% of the population who possess a unique sensory processing trait which allows them to pick up more on subtleties in the environment, resulting in deeper processing and often being easily overwhelmed with stimuli. HSPs are often gifted with having a rich inner life, complex imagination, and deep empathy for others.

Most HSPs exist on a spectrum of sensitivity, with about 1 in 5 HSPs who are considered High Sensation Seeking. High Sensation Seeking HSPs often experience life with ‘one foot on the gas, one foot the break’. Since they are often drawn towards stimulating environments, they often don’t appear as your ‘typical’ HSP. However they often need more time to recover from those stimulating experience than non-HSPs.    

As a therapist in private practice, you have plenty on your plate. Networking, continuing education, billing and insurance, not to mention the emotional work of hearing client’s stories of suffering and pain day after day. Given HSPs make up only 15-20% of the population, why should you care about them? And why do they matter to your practice? You might be surprised.  

 

1) HSPs Are Probably Already Your Clients

If you are thinking to yourself that you don’t have an HSP clients, think again! Remember that fun 80/20 rule? Dr. Elaine Aron (the official HSP guru) believes that, in psychotherapy, HSPs are the 20% of the population that make up 80% of your client base.  

I suspect you have at least one client on your caseload who is highly sensitive (or a high sensation seeking highly sensitive person). They may be aware of their trait and embracing it, aware of their trait and fighting it, or not aware of this trait at all.  

You already take into account many demographic details of your client, such as age, cultural background, gender identity, and trauma history. Why would you ignore your client’s innate temperament in the care you provide? Wouldn’t you want to know a critical detail about your client’s nervous system and adjust your treatment approach and expectations accordingly?

 

2) They Are Your Most Loyal Clients

When HSPs are receiving supportive therapy, in a setting where they feel valued and cared for, they will become your most loyal and dedicated clients. You may see them make progress fairly quickly. They probably will continue to see you even after the original issue has been treated.

One reason for this phenomenon is that many HSPs learn to view self-care not as a luxury, but as something inherently necessary for them to manage a delicate nervous system in a stimulating world. With their capacity for deep emotional and intellectual processing, therapy is a consistently needed outlet for their busy brain. If the client has the resources to do so, they may see seeking outside support from a therapist as a lifelong investment, not something that only occurs when they are in crisis or their needs are acute, although this may be how they initially come to your practice.

Even after their original issue has been managed, you can expect them to continue to support your business, either by continuing to see you for maintenance sessions, bringing their family and friends to you, or by sending clients your way who are also HSPs.

 

3) They May Be Your Most “Complex” Clients

When I use the term “complex”, I refer to clients with multiple concerns who appear to stall on progress despite long term or intensive support. They may also be the clients who you see frequently due to complex and challenging issues. They may be the client where you find yourself continually hitting dead ends or that feeling you are ‘missing something’.  

When treating HSPs, one must take into account how HSPs are impacted by differential susceptibility and vantage sensitivity. Simply put, these phenomena mean HSPs may have more long term negative effects than non-HSPs from adverse experiences or environments, but they thrive more than non-HSPs in enriching environments or relationships. Thus, HSPs who experience difficult childhoods are more likely to have anxiety and depression than non-HSPs.  They may even be mistakenly diagnosed with Borderline Personality Disorder.  

The key is not to use the HSP trait as the reason for all your client’s ailments.  It is to understand their susceptibility and take into consideration the delicate interaction between this trait, their environment, and whatever issues they are facing. For example, if your client is a person of color and/or part of the queer or trans community, you must also consider how the compounding impact of racism, oppression, heterosexism or cisnormativity, may impact HSPs vs. non-HSPs.  

When you take high sensitivity into account with your most ‘complex’ clients, you may need to reexamine and reframe your client’s past and current experiences. Stressor that may seem ‘minor’ to you or the client, but can actually have significant impact on an HSP’s psyche and physical health. You may need to support your client in reevaluating their past, lifestyle choices, and experiences with acknowledgement of their HSP trait. From there you may uncover some of the blocks to the client’s recovery and healing.

 

4) Awareness of a Client’s Sensitivity Can Improve Treatment Outcomes.

If your client is an HSP, you and your client have the potential to become frustrated or dishearten with lack of progress or barriers if you are not taking into account the client’s sensitivity. This may manifest as having the focus of treatment goals is in opposition of their innate temperament. You and your client may be frustrated because therapy goal’s are not taking into account your client’s finely tuned nervous system.  

You will never find a cocktail of medication that will prevent HSPs from processing deeply or being highly sensitive (although some clients report certain medications and supplements can help lessen sensitivity). You will never be able to ‘treat’ an HSP until they are no longer moved by others suffering or deeply empathetic. An HSP will never become ‘cured’ from picking up on subtle stimuli in their surroundings, but they can learn skills to manage overwhelm.

For example, most HSPs who work 40+ hours a week in a stimulating environment don’t have much energy left over at the end of the day. If your HSP client is wanting to be more social in order to meet more friends, but continually finds themselves not leaving the home after work, both of you may feel frustrated of their lack of follow through around social goals. You may see this as resistance, denial, or self-sabotaging behavior. The client may blame themselves for ‘lack of willpower’ or cite social anxiety. However, if you take into account the HSP trait, and the limitations around stimulation during the day, the goal may be to have the client instead look at adjusting their work schedule (i.e. working from home, scheduling more personal days) so that they have the energy to engage in social activity. You can help reframe their social anxiety as actually the anticipatory feeling of getting overwhelmed in certain social setting. Thus, you could encourage your client to attend social meet ups that are in less stimulating environments and help them distinguish between what is social anxiety and what is sensory overwhelm. You both can also reframe what is a realistic expectation around social engagement.   

If you are not able to educate and explore the possibility of your client’s sensitivity, you may continue to set your client up to be unreasonably distressed by something that is an inherent part of them. HSPs are susceptible to mental health disorders that require specific treatment and helping professionals must take into account an HSP’s basic temperament during their treatment process. It is possible for HSPs to learn skills so they do not become highly disregulated or overwhelmed, yet it is unlikely that their will lose their propensity for emotional depth and deep processing of the world.

 

5) Talking About the HSP Trait May Improve Your Relationship With Your Client

Often HSPs are relieved to understand that their trait is not something pathologically wrong with them. If your client is already aware of their sensitivity, even if they don’t have a name for it, they may be relieved to know their helping professional is open to talking about it.  Opening up the dialogue will invite a deep and meaningful conversation that can allow the client to feel valued and seen. This can result in your client feeling more motivated to engage in treatment and also deepen the healing relationship between you.

Keep in mind, it may be initially difficult for clients to hear about the HSP trait. Most HSPs have been shamed, ridiculed, bullied or even abused for their sensitive temperament. In turn, they will often internalize the devaluing of their sensitive nature, as opposed to seeing it as a strength.  

Be mindful of when to broach the topic. You can describe their sensitivity without naming it or without ever using the term “Highly Sensitive Person”. Consider using terms like: sensory processing sensitivity, finely tuned nervous system, or easily overwhelmed or overstimulated.  As you know, the best approach is to use the client’s own language.  

 

6) Discussing the HSP Trait Can Improve Your Client’s Relationships With Others

When clients learn they are highly sensitive, it can help them reframe their past experience and present functioning in a compassionate and new way. In my experience, once HSP clients really learn to embrace their trait, they often feel renewed energy and clarity around setting boundaries around their time, energy, and emotional labor. Many of my HSP clients have been able to finally make career decision that were more suitable to their temperaments, as opposed to what was expected from them by their family and culture. Other HSP clients have become able to frame relationship difficulties with their romantic partner as temperament differences (one is an HSP, one is not) as opposed to a fundamental flaw between them. 

Acknowledging the interplay between a client’s sensitivity and their personal relationships does not eradicate all problems, nor does it excuse legitimately harmful or abusive behavior. Yet, it can allow an increased clarity around the client’s true needs and the open the dialogue for your client to have relationships that are about honoring their innate sensitivity, as opposed to allowing it to be devalued. The first step might be exploring with your client how their sensitivity might show up in the therapeutic relationship.  

 

Moving Forward

If this article resonates with you personality or professionally, you might be wondering how you can continue to learn more about Highly Sensitive People or what your next steps should be.

Your first step is to do some self exploration. Are you a highly sensitive therapist? Are you a high sensation seeking HSP? It will be hard to truly understand the trait in your clients without seeing where you lie on the sensitivity spectrum. You can start with going to Elaine Aron’s website, where she has several self-tests around the HSP trait, including how the HSP trait might appear in children. You might also consider sharing these tests with any loved ones who are also curious about the trait.  

Should you want to incorporate knowledge of HSPs into your therapy practice, the next step is to educate yourself about this trait in the context of a clinical setting. Elaine Aron’s book Psychotherapy and the Highly Sensitive Person is an excellent resource for therapist who would like to start becoming knowledgable around working with HSPs. You may also want to pursue consultation and collaboration with therapists who specialize in working with HSPs.

Whatever path you choose, educating yourself around Highly Sensitive People will undoubtedly benefit your clients and your practice. Hopefully, this exploration will also uncover aspect of yourself and your relationships, bringing increased understanding and clarity to your own life as well.


Guest post written by Arianna Smith, MA, LPC, EMDR

Guest post written by Arianna Smith, MA, LPC, EMDR

Arianna Smith, MA, LPC, EMDR is the owner of Quiet Moon Counseling in Littleton, Colorado. She specializes in working with Highly Sensitive People (HSPs) and LGBTQ survivors of trauma. She has a passion for helping HSPs learn to cope with overwhelm, find belonging, and craft their ideal life. She provides affirming therapy to LGBTQ survivors of trauma and abuse as they embark upon their healing journey. Learn more about her practice here

6 Steps to Engage New Clients in the First Session

Couch photo

When I first began in Private Practice, I noticed that new clients were not coming back for the second session. I knew I was doing something wrong in that first session (or free consultation) that wasn’t connecting with my clients. I started experimenting and tracking my conversion rate.

This is a rough guideline of what I have ‘fallen into’ over the years in private practice that has a very high conversion rate (rate of consults that turn into regular clients for me). I find this can be done in either 30 minutes or 60 minutes. Here are the major steps I do with some of the ‘scripts’ I find myself saying often.

 

1. Welcome/Orienting the client to the consultation session

The consultation session is a little different than a regular therapy session, so I make a point to tell the client what we are going to do, and what he/she will walk away with from our meeting.

Here’s a breakdown:

  1. Greet them and normalize that it can be weird, awkward or anxiety-producing to meet a therapist for the first time (or meet a new one).
  2. Tell them what we are going to do during today’s meeting. The important points to hit are:

  

  • This is a time to get to know one another a little bit
  • I’m going to be asking some questions to know what’s been going on for the client
  • I’m going to be answering any questions that they have (I tell them it’s ok if they don’t have any)
  • I’m going to share my thoughts and initial observations about what they shared with me, so that they know what I’m thinking and it aligns with their experience
  • I’m going to share the general outline of what our therapy will look like (although we can pivot later if needed). This includes a preview of tools I will teach them, the order of things, how we will track progress, etc.

 

I know that’s a lot to get through, here’s a script:

 Hi Jane, thanks for coming in today. It’s nice to meet you in person. I know it can be nerve-wracking to meet a new therapist, and I’ll be asking some personal questions today, so I thank you for taking the step to come in. Today we have a little bit of a different meeting than a regular therapy session. Today I will ask some nosy questions so I can really understand what’s been going on. But don’t worry, you can ask me nosy questions right back if you want to. I’ll answer any questions you have today, but it’s ok if you don’t think of any. After I ask my questions, I’ll share with you only my thoughts and observations about what you’ve told me, so you always know what I’m thinking and to make sure I really understand. Then I’ll share with you my initial thoughts and plan for how I’m going to help you feel better. Ok? Great! Let’s start.

 

2. Super-Short and Focused Diagnostic Evaluation

I’ve found the key here is to not get lost in the weeds, but identify the main clinical concerns right away, then ask a few follow-up questions to understand the severity and symptom presentation of that clinical concern. I save a more thorough mental health evaluation for another time. I want the client to feel heard right away.

Here’s a breakdown:

  1. Ask first about the main clinical concern by asking what brought them in, or how can you help?
  2. Normalize and Validate that concern
  3. Ask a few follow-up questions to get a broad understanding of the issue
  4. Ask about previous therapy experiences, and what was helpful and not helpful about those experiences, so you can quickly learn how the client responds to therapy in general (I make sure to incorporate this into the ‘plan’ that I share towards the end of the consult)
  5. Ask if there are any other major clinical concerns.

 

Here’s a script for a client struggling with Anxiety:

Therapist: Ok Jane, I know we spoke briefly on the phone, but I’d like to just start with a really broad question and go from there, so I will ask what brought you in today?

Jane: Well I’ve been feeling really anxious….

Therapist: I’m so sorry you’ve been dealing with that, it’s really hard. We see a lot of that here in the practice, so you are not alone.

*Now I ask some follow-up questions about this clinical concern, such as:

  • When did it start?
  • How bad does it get?
  • Panic attacks? How many and when?
  • How is this impacting your life right now?
  • Medication? Helpful or not? Prescribed by whom?
  • What helps it right now?
  • Who knows about it? Support network?
  • Family history?

Jane answers all these questions, and I normalize her symptoms along the way.

Therapist: Have you ever seen a counselor before for this or for anything? When was that? What was helpful about that? Anything about that not helpful?

*I’m listening for anything that the client found helpful in the past in therapy (if they have done it). Things like a therapist being directive, providing honest feedback, teaching tools, etc.

Jane answers….

Therapist: So I really hear you about the anxiety and am starting to think of some things we can do together that will really help that, but first let me ask, is there anything else going on that you think is important for me to know?

Jane answers…

 

3. Feedback to Client

This is where I thank the client for being so open and talking about difficult things, and provide feedback and a rough/initial diagnostic impression. I’m not rushing a diagnosis, and I don’t use that language (usually) with the client, but just like when you see the doctor, you want to know what they are thinking and that they understand why you came in. I emphasize that I hear them, reflect their own language back to them, and validate that their concern is not ‘just in my head’ but it’s serious enough that they came to a therapist about it, and that they deserve a professional’s help to feel better.

Here’s a script for our client Jane:

Thank you for answering all those nosy questions, Jane. I know this stuff is hard to talk about. It’s very clear to me that you have an above-average amount of anxiety and it’s really impacting your ability to sleep and your job. That must be so hard. You should know that what you have shared with me is not a normal level of anxiety that we all feel from time to time. I hear some markers of an anxiety disorder, and so you’ve been dealing on your own with a clinical issue. You can’t just make it go away by being hard on yourself, which I already hear that you are. If you could kick this by just telling yourself to calm down you wouldn’t be here right now. But you are, and I’m glad you are. You don’t need to be alone with this anymore.

In our next session I’ll ask some more about your symptoms and really make sure we get the right idea of what you’re dealing with, but I’m pretty confident in what I’ve heard that the focus of our work with be tackling this anxiety together.

 

4. Share Your Initial Plan (let the client know that you can help them)

This is such an important step. The client wants to know in a concrete way how you will help them with their issue. You don’t need to do an on-the-fly treatment plan, but as you listen to any clients, ideas pop into your mind of what may work well for the client. This is your time to share that, give examples, and give the client confidence that you are in control, that you ‘get’ them, and that you have a plan.

Things to keep in mind for this step:

  1. Frame the work in terms of ‘we’ rather than ‘you’ or ‘I.’ You and the client are a team now.
  2. Share an honest initial time-frame with the client. You’re not tying yourself down to that timeline, but you will have a sense of how ‘easy’ or ‘difficult’ the client’s issue is, so share that.
  3. Incorporate what was helpful about previous therapy (If there was any)
  4. Reflect the client’s own language in how they describe their symptoms to you, so they feel heard and understood. Don’t use overly-clinical or ‘jargony’ language.

Here’s a script for Jane:

I feel confident that we can get this anxiety under control and you can feel like yourself again. If you choose to work with me, I’m think that first we will jump right in to concrete and practical tools to help with your anxiety in the moment. I remember with your therapist back in college you liked having those tools you could turn to, so we will start there. We will also explore the causes and triggers of your anxiety so we can play offense, not just defense. We want to see those things coming, have a plan, and head them off. I will also work with you on some pretty easy tweaks to your sleep routine to get you some better sleep, which will help with anxiety. I think also, from what you have shared with me, that simply having someone to talk to about all of this will be helpful. You’ve felt alone and embarrassed about it, and I understand. But talking about it will help us move past the shame and implement these tools and strategies. I think we can really see a difference in around 3 months, based on my work with other clients who are going through what you’re going through.

 

5. Answer The Client’s Questions and Wrap-Up (giving them a choice to schedule for follow-up with you).

The last step is to ask if the clients have any questions for you. I usually find that at this stage, you’ve answered all of their questions. However, sometimes they have questions. I answer all of them as transparently as possible. Clients hardly ever ask a personal question. The most common question I’m asked is basically ‘Am I weird’ and ‘Can you help me?’ Those are easy times to validate/normalize and again reinforce your very rough treatment plan.

After that, we wrap-up and I see up the next session. I never want to pressure anyone, or assume that they feel comfortable being my client yet, so I give them a choice between scheduling our next session right now, or getting back to me after they think about it. Almost 100% of the time they schedule right then, but if they don’t, that’s ok too. I always remind myself that ‘you’re not for everyone’ and let it do. Oftentimes, the client that doesn’t ‘sign up’ right away will circle back to me in the future.

Here’s a script to wrap up:

Well Jane we’re almost out of time, I’m sorry to have to stop. We can do one of two things from here. If you feel comfortable that we’d be a good fit, we can go ahead and schedule our next session and I think it would be good for your progress to meet every week. If you want to think about it, that’s fine too. If that’s the case, I’d love your permission to follow-up with you via email in a few days so we can touch base before my caseload fills up again. What would you like to do?

 

6. The Follow-Up Email

I always send a follow-up email, no matter what (unless they tell me not to email them). This lets the client know that you’ve continued to think about them. It’s also an opportunity to offer something of value. I email with a short note saying it was really nice to meet them and, if they have ‘signed up’ to be a client, that I look forward to working with them. I say I have been thinking more about what they shared with me, and it make me think of this helpful article/book/podcast that I wanted to share and include a link. That’s it! Clients tell me they really love this follow-up.

This is also an opportunity to ask if a client wishes to meet again (if they didn’t schedule during the first consult).

Here’s a script:

Hi Jane,

I really enjoyed meeting you yesterday. We talked about some hard things, and I appreciate your openness. I was thinking further about that panic attack you had last week, and wanted to share this article about riding out panic attacks. It may be a good idea to share this article with your husband too, because I remember you mentioned he felt a bit powerless when that happens. Here’s the link to it. If you’d like to meet again and get started on the goals we spoke about, let me know and we will find a time what works with your schedule.

Warmly,

Erin


Guest post written by Erin Carpenter, LCSW

Guest post written by Erin Carpenter, LCSW

Erin Carpenter, LCSW, is a therapist in private practice and owner of Thrive Counseling, a group practice in Southeast Denver. Find out more at http://www.thrivecounselingdenver.com

Community Confidentiality: Supporting Collaboration with Consent

confidentialcommunity.jpg

“I cannot confirm or deny.” How do you maintain confidentiality for your client? It may seem easy enough when there is a clearly written, signed release or when your client refuses a release, thus declining collaboration at this time. However, what does it look like in the following situations?

  • Your client is involved in an open Child Abuse and Neglect case.
  • An attorney calls you saying they represent your client and would like copies of your client record for a disability claim.
  • An insurance company calls to report the client listed you as a provider and they want to know your diagnosis to award the client a life insurance policy.
  • You outreach an organization about who they serve. They respond by wanting to obtain additional information from you on the client you want to refer.
  • A referral source wants to know if their client called to set up an intake and begin services with you.
  • A community resource shares that your client scheduled an appointment with them for next week.
  • A foster parent wants to know why the parent isn’t engaging in services to reunify with their child.
  • A CASA volunteer wants to know if the family is working on their fighting in your sessions because they believe it would be helpful.
  • The spouse of your client calls asking you how sessions are going.
  • Your client acknowledges that their friend is also your client.
  • Their probation officer includes you in a group text or email to schedule a meeting on behalf of the client with several parties you don’t know.

These are just a few of what could be dozens of examples of sticky situations when it comes to maintaining your client’s right to privacy. Let us look at possible responses to the above scenarios to determine what could be best. And as always, seek consultation, supervision, or legal advice if you have needs or concerns.

 

Signed Release

When a third party reaches out to you by email, text, or voicemail, it can be helpful to notify your client and obtain a release in the next scheduled session. Notifying your client of the outreach you received can support trust and transparency in the therapeutic relationship. It can also help facilitate a discussion on the importance of getting a client’s written permission to respond to an inquiry on their behalf, whether it’s an insurance company, secondary referral, family member, or community partner.

 

Legal Requirements

Perhaps your client is involved in an open Abuse and Neglect case, diversion, or probation. These entities have been assigned to your client as part of a larger treatment plan to address a legal concern. Whether your client is mandated to complete therapy or the third party referred directly to you, there is a different level of confidentiality implied due to the collaboration needed from you to provide progress reports and updates as appropriate around your client’s engagement in services. If you client is resistant to signing a release, helping them identify the specific pieces of information to share—and thus restricting some information in the effort of privacy—can be helpful to the client’s anxiety about personal information that is disclosed to others. When submitting a progress report to DHS or probation for example, providing your client with a copy can also demonstrate a sign of transparency and trust in encouraging them to review it and provide feedback on their level of comfort with the material shared.

 

Sense of Urgency

The desired scenario is one of those mentioned above, where we have the client complete a signed release of information highlighting exactly what is released and for what purpose. However, there are times that a sense of urgency may arise in getting permission quickly to collaborate with a community partner in a timely fashion. Depending on the frequency of client contact including regularly scheduled appointments, you may need to get email or verbal permission over the phone from your client as a temporary measure in obtaining consent prior to a written release. Standard practice is to have permission in writing so email can feel slightly more comfortable than verbal permission to us as providers. Either way, documenting your client’s permission with intention to get a full release in the immediate future can be helpful in allowing collaboration and sharing of information under a time restriction.

 

Curbing Curiosity

Collaboration is a helpful component of therapy, within reason, to support and validate client efforts. It may become apparent that there are other parties involved who may want updates on your client’s progress. This could include caseworkers, probation, child advocates, other mental health providers, foster parents and more. Where it can feel confusing is when third parties know you are actively working with the client and make assumptions that you can share information in the spirit of collaboration. For example, the foster parent is wanting to know how the parent, your client, is doing in services in order to encourage their child of the parent’s hard work. The inquiry may feel innocent enough, however the foster parent is not your client, and is therefore not privy to this information without your client’s consent. Something as innocent as attendance or participation in services can be reported back to other parties and could result in information being misconstrued or shared without permission.

 

Encompassing Electronics

In an effort to not have information shared unintentionally with third parties, being mindful of how your electronic correspondence is recorded can be helpful. Being aware of emails with additional recipients or group text messages requesting scheduling of a team meeting can feel nebulous regarding confidentiality. Documenting your effort to send correspondence only to approved parties identified on a signed release supports your client’s wishes as well as ethics compliance. Providing disclaimers in your electronic signature in email composed on your computer or phone can also support limiting liability if information is sent to the wrong recipient or forwarded to a third party outside of your control.

 

Limiting Liability

Documenting each of your efforts to maintain confidentiality as a standard of your practice can limit liability. Obtaining regular releases yearly from your client can keep their record up to date. Utilizing encrypted email and electronic health records for client progress notes can restrict situations where their information could be compromised. When it comes to confidentiality in direct interaction with third parties, identifying a statement of “I cannot confirm or deny they are my client” can feel unhelpful, restrictive but necessary in not admitting unapproved information to family, friends, referral sources, or legal representatives without permission. This feels most challenging by phone when even acknowledging your need to obtain a release is admission of your client’s connection to you. For many, having to share that a release has been revoked can feel even more challenging. You may say something like “permissions have been revoked and we suggest you contact the person of interest directly” can provide enough information for them to understand you won’t be interacting with them further and prevents direct identification of your client by name or circumstance.

Communication with community partners is an intricate dance that can feel challenging when caught off guard by emails, texts, or phone calls asking for updates on your client’s work. Demonstrating your ethical capacity in delaying disclosure of information until a release is obtained can indicate your professionalism in the community and willingness to collaborate under the appropriate circumstance. Be sure to follow up with the community partner once a release is signed to further demonstrate your willingness to collaborate together. Lastly, thinking about the possibly scenarios that put privacy at risk and obtaining signed releases upon introduction to the client can streamline this process by simply asking who else is involved in their treatment or care. Having a scripted response ahead of time for situations where a release is not yet completed can support you in making the best decision to support client confidentiality and community engagement with consent.

Clinical Writing: Consistency and Confidentiality

ClinicalWriting.jpg

A question heard frequently in private practice is how do we stay on top of paperwork when our passion is engaging the client in doing meaningful work? What if clinical documentation supports them in getting additional resources such as disability or explores reunification with their children? When working with individuals or families involved in the Department of Human Services (DHS), probation, diversion, or other entities evaluating your client, the documentation you keep takes on an additional level of importance in capturing the client’s progress. So how does one balance recording the content of the session consistently while protecting client confidentiality? Balancing requirements for documentation with client privacy is an art form that requires consistency and practice.

 

Construction of Case Notes

Depending on your preference for hand written, typed, or electronic notes, your content and formatting of those notes could be dictated by private or state assistance insurance panels in order to process claims and receive payment for services rendered. With this in mind, most insurance panels require the following to be identified in each note:

  • Full name of client and insurance ID
  • Date of service
  • Time of Service
  • Duration of Service
  • CPT Code that indicates individual therapy, family therapy, case management, etc.
  • Overview of therapeutic interventions utilized in the session
  • Progress towards identified treatment goals
  • Current mental health diagnosis
  • Client presentation in session
  • Next scheduled appointment

By formatting your notes in a similar fashion, you can streamline any documentation needs from secondary parties desiring collaboration. Don’t forget a signed Release of Information from your client to facilitate collaboration!

 

Consistency in Content

Formatting not only provides the outline of a universal progress note, it can support consistency that will reduce the time spent on notes each week. Many therapists report frustration that their notes are behind schedule due to wanting to dedicate their time and energy to the client work. By utilizing a template for notes, it will become easier and more efficient to complete notes in a timely manner, especially in utilizing clinical language. When struggling with how to write clinical language that captures the professional interventions present in each session, it can be helpful to have some go-to phrases that indicate progress without providing too much detail. Here are some examples of common content and professional language that could be helpful in writing clinical notes:

Content Table

 

Confidentiality for Clients

In addition to clinical documentation supporting professional record keeping in line with ethical requirements, another component it can support is client confidentiality. It can feel like a fine line providing adequate written evidence of professional interventions without violating client privacy.

One strategy to ask yourself is, “would my client feel uncomfortable with my notes being seen in court or by others?” If the answer is yes, you may want to re-evaluate how you write your notes to support clear, concise interventions that would not put confidentiality at risk. Below are some documentation tips to consider in supporting client privacy:

  • Keep client direct quotes to a minimum.  They are best included when capturing safety concerns. Client reported “I want to die” leading to assessment and safety planning in session.
  • Avoid emotion-driven language without evidence such as, client was happy/sad/angry in session.
  • Support ownership of statements such as, this writer observed or client reports when documenting statements or content of a session.
  • Keep language neutral. It is best to avoid a positive or negative tone in notes to prevent accusations of bias or alignment that would put professionalism in question.

It is recommended you seek consultation or supervision to further explore your documentation needs. Your professional organizations can provide ethical guidelines whereas insurance panel websites offer Providers valuable templates for clinical documentation that meet audit standards. With luck, you will perfect your clinical writing to maximize time in therapeutic interventions while remaining compliant with documentation needs to best serve your clients and your practice.

Streamlining Your Business Process: 7 Tips for Private Practice

streamline.jpg

A new year has begun! For many mental health professionals, we are resuming our schedules after holiday travel and hoping to start the year off right! What are your goals for the year? Perhaps you want to streamline your paperwork process to maximize time with clients? Or maybe you want to explore a billing support business to stay on top of your insurance claims and expenses? Perhaps you want to transition to only taking private-pay clients so you aren’t required to identify a diagnosis and can work with clients from a different lens? So how do we stay on top of our thriving practice addressing client needs and interventions while still remaining compliant with the more mundane and time-consuming processes of paperwork and billing?  Below are some tips and tricks to consider in maintaining a balance of both organization and time management!

 

Tip #1: Go Paperless

In today’s day and age, technology continues to enhance our processes of organization and time management. Consider going paperless with your client note system to complete paperwork in less time. Companies like SimplePractice, TherapyPartner, and TherapyNotes offer encrypted, protected and thus confidential note systems that can support your client files electronically as well as connect clients to appointment reminder texts and emails and offer billing services to streamline claims submissions and payment.

 

Tip #2: Set a Schedule

When trying to balance your time with clients and stay on top of paperwork demands, it can help to set a schedule.  Setting aside some time daily or weekly to submit your billing not only helps you complete it when the content is fresh in your mind and getting paid in a timely manner, but can assist you with leaving work truly at work, representing a transition ritual from work to home.

 

Tip #3: Use a List

This may seem strange when we’ve just discussed the benefit of going paperless bur having a to-do list where items can be crossed off when completed can be very satisfying. Consider using a planner or notebook that’s with you at all times. For others, consider using your to-do list in your phone where you can set reminders and due dates for completion. In our busy world, it can be hard to keep track of everything so a list that’s accessible from anywhere at any time can help record thoughts and ideas that come up in our daily living.

 

Tip #4: Creating Connections

Staying on top of trainings, webinars, books and other materials can help you streamline your niche and business practices. There any many great materials out there but we especially love Simon Sinek’s Start with Why in discovering what drives us as helping professionals and business owners. Joining an online community for mental health professionals can also be helpful in asking in-the-moment questions about business practices.  We suggest checking out The Private Practice Startup and Building Brilliance as two online communities that offer tips, tricks, and offer access to a community of like-minded individuals.

 

Tip #5: Have a Business Plan

Working as hard as you do, it helps to have a business plan to create a sense of direction. Is your goal to have 20 clients per week consistently? Do you want to expand to include other insurance panels to serve more clients? Perhaps you want to identify a stream of secondary income? By creating and reviewing your business plan on a regular basis, you can check in on both short and long-term goals of being your own business. Templates for creating a business plan can be found online.

 

Tip #6: Have an Accountability Buddy

Even with a business plan, life can sometimes get in the way of tracking where we are headed. Combine that with how private practice can feel isolating at times and we can find ourselves procrastinating or drowning in the details. Connecting with a colleague and identifying one another as our accountability buddy can help hold us to our goals as well as remain connected within our community. Engaging your accountability buddy can help inspire your process, define your goals, brainstorm strategies to achieve those goals, and celebrate your successes along the way.

 

Tip #7: Take Time Off

Being a business owner can take a lot of our time and energy. Don’t forget to take time off to prevent burnout and allow creativity to flow from s different headspace in another environment. We know that being our own business means we can potentially work 24/7 not only in serving clients but the behind-the-scenes responsibilities. Time off can support us in being grounded, compassionate clinicians as well as focused, driven business owners who can enjoy the results of our hard work and remain inspired to continue to serve the populations we value most.

5 Things to Know Before Creating an App in Private Practice

WebApp

Cell phones, tablets, laptops, oh my! Technology is providing us with new tools and a media presence that can jump-start a private practice! It can be both exhilarating and intimidating. Luckily there are supports out there for those who want to explore the benefits of media in their marketing and branding. Consider media experts who support mental health professionals, such at FYLMIT.com, which provides professional marketing videos to therapists around the country in support of growing practices and facilitates a connection between the therapist and a potential client.

If you are in a place of wanting to explore secondary income within your private practice, consider developing an app that could support your clients or community. The following tips and helpful hints can help you feel prepared for navigating the journey into technology of creating an interactive app!

 

Know how to select the best developer

Have a clear vision about what you are trying to accomplish by developing an app. Create a written, detailed plan and place it on a freelance site such as upwork.com to receive proposals from interested parties. Review proposals from freelance web developers and computer programmers and explore their ratings on the site, including response time to inquiries, availability to take on a new project, and references from former clients. Lastly, don’t hesitate to interview your top choices to get a sense of their communication skills and strengths as you will be communicating a lot with them should they join you on this project!

 

Know your budget

The costs of an app can be broken down into start-up costs and ongoing costs to maintain the app once it’s live. Depending on the complexity and components of your desired app, expect a quote from a web developer between $4,000-$20,000 to create it. Consider the ongoing costs of maintaining, updating, and structuring the app features to support your desired audience. In addition, explore each web developer’s payment plan to determine if they invoice for the work completed, expect a certain amount at the beginning of the project, and/or are willing to develop a payment plan with you.

 

Know your audience

Who are your desired users and how can you reach them? If your app utilizes several internet sources, perhaps it the best fit to develop a web app that requires internet connection and is built on a web browser. Or maybe your desired audience is accessing your app more on their phone where a mobile operating system first builds the app which is then pre-installed on their phone through an app store. Identify how your desired audience will find and use this app and select the option that gives them the greatest access. Also remember to think long-term about costs of maintaining or updating the app and how updates can be built into the app program to keep your audience engaged.

 

Know the legal implications

Engaging clients or community partners through an app can have it’s challenges. Be sure to consult with a legal representative on confidentiality and client identifiers. You may be advised to develop and use liability disclaimers to not assume responsibility for misuse of your app by those who use it. Explore intellectual property law with a free consultation by a trusted legal source to determine if trademarking, copywriting, or patent are appropriate options for content of your app. Finally, don’t forget to also consider having your web developer sign a non-disclosure agreement (NDA) to protect the content you create from being shared or sold to a third party.

 

Know what sets your app apart

Your app is in production, now it’s time to determine how to market it. Researching apps that others use in our field can assist in determining the value of offering your app as free, having a one-time fee, or ongoing costs to a user that are justified as improvements or additional features as part of an upgrade. Consider the audience interest of your app by exploring if there are similar apps out there in use. Know your competitors and explore what would encourage a user to select your app over the competition, such as a streamlined, more user-friendly interface or affordable price.

Finally, your app is ready to go live! Working with the tips above, you will have invested in a piece of your business that reaches new audiences beyond your private practice and an interactive component of technology that can have a lasting impact! To learn more about our personal experience in creating an app, check out our guest podcast with The Private Practice Startup here.